Incorrect 12 lead interpretation

[nursej22, MSN, RN]

Question for y'all, and a bit of a rant.

First, the question: do you rely on the computer interpretation printed on the twelve lead or do you do your own interpretation?

Now the rant:

A couple of evenings ago, as charge nurse on our cardiac floor I get a request for an asap transfer from the medical tele floor. Apparently the patient had developed a serious arrhythmia just as they were transferred from ED, admitted with weakness, or near syncope, or some such thing. Ok fine, we have staff and housekeeping is just finishing a room so we take her in a few minutes or so. I look her up on the EMR, history, labs and her 12 lead done in ED. The 12 lead interpretation is benign but wrong. The same arrhythmia that is transferring the patient to our unit is clearly visible. According to the EMR, the ED RN, the ED MD, and the admitting provider all felt she had the benign rhythm described on the 12 lead. The tele tech was the first person who correctly identified the patient's rhythm, later confirmed by a cardiologist.

Wow, just wow. I know its been crazy busy, but how the heck did all 3 miss this? This thing was textbook perfect, right out of Dubin's, right off the ACLS test.

I hesitate to be more specific due to HIPAA.

Does anyone else see this happening?

[dianah, ASN]

Never rely on the computer interpretation.

Do your own, with a reliable and orderly review of components.

[Anonymous865]

Since I'm not a nurse, I wasn't going to respond. Since no one else is responding, I will tell you that as a patient I have experienced something similar to what you described in your rant.

I had my 1st ekg at 29 for an employment physical. The computer read the ekg as 2 MIs age unknown. Fortunately when I went to my wonderful internist with the ekg from the company Dr, she quickly diagnosed it as Wolff Parkinson White syndrome. She then confirmed it with an echo.

The computer always reports MIs or inferior infarct or something similar on all my ekgs. Routine echos and nuclear stress tests over the past 27 years continue to show a healthy heart.

Recently I had to have urgent surgery at the local research / teaching hospital. I informed them that I had WPW, inverted Q waves, and low voltage in the T ways, but that this was "normal" for me. They did an ekg a few days before my surgery. The computer read it as "inferior infarct." That diagnosis was confirmed by the cardiology resident and the cardiology attending!

Once again my wonderful internist looked at the ekg and said nothing had changed since my last ekg, echo, and stress test. To be cautious she ordered an echo that was read by the internist and my cardiologist. Still just the WPW.

As someone with a graduate degree in computer science, I would tell you never use the computer's interpretation in place of your own judgement. The computer's diagnosis is based on probability. E.g. the code would say, if you see x, y, and z, then the probability is 80% that the diagnosis is a, 12% that it is b, 7% that it is c, so it reports the diagnosis as a. We can't program in EVERYTHING that a person takes into consideration because some of that is just the person's experience and instinct.

[dianah, ASN]

Thank you, Anonymous865.

And, I suggest you carry a copy of your latest ECG with you, so in case you are ever hospitalized away from your home network, they will have one of your "normal" ones to compare with their newest.

[fakebee]

I'm confused-how does a benign rhythm on an admission EKG turn into a serious arrhythmia requiring transfer if it's the same rhythm? What was he rhythm?

[nursej22, MSN, RN]

Well, as I stated before, because of HIPAA, I don't want to state what it was. But another example is a sinus bradycardia that looked benign except that the QT was so long that it was nearly in the next QRS complex. The computer didn't catch that, but the cardiologist did. The patient was at risk of going into Torsades. Got magnesium replacement and stopped a med notorious for QT prolongation.

[turnforthenurse, MSN, NP]

It isn't a HIPAA violation unless you use specific patient identifiers, i.e. their name, MRN#, etc.

I never rely on the machine's interpretation. I do my own but of course the provider is the one who needs to look at it and make the official interpretation. Example: as I was obtaining an EKG, it showed some movement in the tracing in leads I & avL that looked like ST-segment elevation. When I captured the picture, that particular tracing popped up on the screen, and it read as an acute, lateral MI. There were no reciprocal changes on the EKG and of course I captured a different "picture" because there was movement on the previous tracing. With the patient being absolutely still? Sinus rhythm. No ST-segment elevation, T wave inversion, prolonged PR interval, QT prolongation, nada. Just a textbook-perfect sinus rhythm.

My point? Don't rely on the machine's interpretation.

[ChristineN, BSN, RN]

At my facility all EKGs must be read by the attending physician of the pt soon after they are obtained. The EKG is also uploaded to a computer file where a formal read is done by a cardiologist, typically within 24 hrs. As a nurse, I know a little about reading 12 leads, but the ultimate interpretation is up to the physician.

[Anonymous865]

Thank you, Anonymous865.

And, I suggest you carry a copy of your latest ECG with you, so in case you are ever hospitalized away from your home network, they will have one of your "normal" ones to compare with their newest.

Dianah, thank you for your excellent suggestion. I always carry a list of prescription and OTC meds I am taking, so it would be very easy to staple the latest ecg to that. Since I travel constantly all over North America for my job, I could easily end up in a hospital outside of my network. Most providers will call my PCP to get my records, but why add work for the nurse / doctor when I can just carry it. Thanks again for helping me be a "good patient."

[mcdebb]

I am a medical asst. working in a Cariologist office. We do NOt allow our 12 lead ekg machines to print an interpretation, we Must ALWAYS have the cardiologist write their interpretations and signed ever ekg before scanning into the system by the next morning.

Good catch on your department!

Take Care, Debbie

[TraumaSurfer]

It isn't a HIPAA violation unless you use specific patient identifiers, i.e. their name, MRN#, etc.

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HIPAA does not have to apply for something to be a privacy violation either/or/and state or facility. If the OP has ever posted something to identify where he or she works that narrows it down.. The forums are also not that anonymous since the IP is know as well email identifiers. If you post something that a co-worker might pick up on, you could expect to be questioned about it. As some say....small world.

[nursej22, MSN, RN]

Thank you, TraumaSurfer. I suppose I was using "HIPAA" as a catch-all for privacy issues, esp. related to my workplace policies.